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A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children prior to suturing

Ray McGlone, Trevor Fleet, Stuart Durham, and Sally Hollis

Abstract
Objective -
(a) to compare the use of high dose intramuscular Midazolam with and without intranasal Flumazenil in children after suturing.
(b) to compare the use of high dose intramuscular Midazolam with low dose intramuscular Ketamine in children prior to suturing.
Methods - 87 consecutive children, aged between one and seven years, presenting with simple wounds, were studied. Children considered combative (n=47) were given ketamine (2.5 mg/kg i.m.). The remaining 40 children were given midazolam (0.4 mg/kg i.m.) with and without Flumazenil (25 ug/kg, intranasally).
Results - The median Oxygen saturation was 97% in both midazolam groups. Flumazenil significantly reduced the amount of agitation during recovery (P=0.048) and also the time at which children were ready for discharge (Median 55 versus 95 mins p value <0.001). After discharge both midazolam groups had an unsteady gait (75%) and there was no significant difference in the duration.
As expected due to the deliberate selection of combative children into the Ketamine group, the pre-sedation behaviour was slightly more disturbed compared to the midazolam group (p=0.10). However the Ketamine group was less agitated during local anaesthetic and suturing p<0.001.
Conclusion - Intramuscular midazolam (0.4 mg/kg) did not effectively sedate the children, in that a significant number still had to be restrained. However none could remember the suturing. Intranasal flumazenil appears to be effective in shortening the time to discharge. If midazolam is to be used then a dose high enough to produce full amnesia should be used, there appears to be no advantage in increasing the dose further. Low dose intramuscular ketamine remains the drug of choice.
Keywords: Suturing; Children; Midazolam; Intranasal Flumazenil; Ketamine